Hospitals covered
APA Insurance – Health Coverage Details
1. Insurance Overview
APA Insurance offers health coverage through its Afya Nafuu and Jamii Plus medical plans. These plans are designed for individuals, families, and groups, providing core inpatient cover and optional benefits like outpatient, maternity, dental, and optical services. apainsuranceke.org+2Scribd+2
2. What APA Covers Under Its Medical Plans
| Service Type | Coverage / Benefit |
|---|---|
| Inpatient (Hospitalisation) | Covered under all core plans. Includes bed charges (ward, ICU, HDU), surgical fees, specialists, and doctors’ fees. apainsuranceke.org+1 |
| Diagnostics / Laboratory | Lab tests, X-rays, ultrasounds, MRI, and CT scans are included under inpatient core benefit. apainsuranceke.org |
| Medication / Prescribed Drugs | Prescription drugs and dressings (post-hospitalisation) are covered. apainsuranceke.org |
| Chronic / Pre-existing Conditions | Chronic illnesses, HIV/AIDS, congenital conditions, and psychiatric conditions are covered (after 12 months with full disclosure). apainsuranceke.org |
| Maternity & Newborn | Optional add-on. Covers normal delivery, C-section, ectopic pregnancy, complications, and related hospital stays. apainsuranceke.org+1 |
| Outpatient (GP, Specialist) | Optional benefit. Covers consultations, diagnostic tests, and prescriptions when added. Step By Step Insurance |
| Dental & Optical | Optional add-on. Covers cost of inpatient dental (after accidents) and optical treatment. apainsuranceke.org |
| Personal Accident | You can include a personal accident benefit in some plans. apainsuranceke.org |
| Funeral / Lodger Fees | Lodger fees for admitted patients are covered. Funeral expense benefit also exists in some plans. apainsuranceke.org |
| Evacuation / Overseas Care | Overseas inpatient referrals and credit-based inpatient care in listed hospitals. apainsuranceke.org |
| COVID-19 | COVID-19 is explicitly covered in their Afya Nafuu plan. apainsuranceke.org |
3. Coverage Limits
APA’s Afya Nafuu has different plan tiers with yearly inpatient limits up to KES 2,000,000, depending on the plan. apainsuranceke.org
Outpatient core plan limits range (example) from KES 30,000 to KES 100,000, depending on the plan. apainsuranceke.org
Bed charges are “net of NHIF” (i.e., APA pays what’s left after NHIF portion). apainsuranceke.org
4. Pre-Authorization / Approval Requirements
Hospital admissions (especially inpatient stays) usually require pre-authorization. apainsuranceke.org
Diagnostics like X-ray, MRI, CT and other high-cost investigations may also need prior approval, depending on policy.
5. Co-Pay / Co-Insurance
The specific co-payment or co-insurance varies by plan; APA’s policy documents indicate outpatient benefit is optional, meaning co-pay depends on whether the cover was added. Step By Step Insurance
For inpatient, the co-insurance or cost share depends on the selected benefit tier.
6. Waiting Periods
Chronic / pre-existing conditions (like HIV/AIDS, congenital) have a 12-month waiting period when enrolling. Step By Step Insurance
For maternity benefits, there may be a waiting period before they become effective, depending on the plan. Step By Step Insurance
7. How to Use APA Cover at a Hospital
Provide your APA policy number and card at hospital registration.
Present a valid ID (e.g., national ID / passport).
Notify APA for planned admissions or complicated procedures to get pre-authorization.
After treatment, the hospital bills APA (if in-network) or you may need to submit a claim depending on your plan.
8. Required Documents
APA Insurance card / policy number.
National ID or Passport.
Pre-authorization request / letter for planned inpatient admission.
Maternity: any required declarations or pregnancy-related documentation (if maternity cover is included).
9. Exclusions
Some services may not be covered depending on the plan:
Non-medically necessary cosmetic procedures.
Unapproved or experimental therapies.
Services outside the network (if your plan restricts to specific providers).
Self-prescribed tests (for certain contracts) based on scheme documents. tenderskenya.co.ke
10. Value-Added / Unique Features
Post-hospitalisation benefit: APA offers cover for medical follow-ups after discharge. apainsuranceke.org
Funeral expense benefit: Some plans include payout for funeral when policy is active. apainsuranceke.org
Personal Accident cover: Optional add-on provides extra protection. Doctor 4 Africa
International Care: APA provides for inpatient care overseas on credit basis for selected hospitals. apainsuranceke.org
11. Hospital & Insurer Contact Details
APA Customer Care / Claims: +254 709 912 777, email: info@apainsurance.org apainsuranceke.org
Emergency / Medical Admissions Contact: +254 709 912 888 apainsuranceke.org
FAQs / Application: On their site under “Afya Nafuu” product. apainsuranceke.org
12. Disclaimer
This summary is based on information from APA Insurance’s public product brochures and policy documentation. Benefits, limits, and coverage depend on the exact plan you choose. Please confirm all your coverage details, waiting periods, and requirements directly with APA or via your policy contract before seeking treatment.